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Hello All
I am a 47 year old male living in Kansas City. I am in well above average physical condition. I exercise regularly and am mostly careful with my diet. I am writing my first blog entry while learning to use it. It is unfortunate that I only discovered this blog after my surgery. As I have read the experiences of others I have come to appreciate the importance of this blog. I write to help others as I have been helped, to get to know and make new friends through this trial (one of the few positives) and to make an account of my own experience. I want everyone to know how grateful I am for you all taking the time to recount your story. Especially some of you who seem especially focused and well researched. I really enjoy hearing contrary opinions in a truly objective and yet caring environment. As an aside I would note that this blog seems to have taken on an especially caring and dynamic culture. It is interesting that an ‘electronic’ community can develop such a warm culture. Probably the catalyst of common suffering that draws this tribe together
My son plays Strong Safety for Kansas State University. He was home for Father’s Day weekend. He and his friends were playing basketball on the driveway that I had especially designed for pick-up basketball games. I joined in and ruptured my Achilles. I jumped for a rebound with no one around me, came down, heard a pop and thought someone had kicked me in the back of the leg just below the calf. I had been playing for a little more than an hour. I have had many injuries playing sports but never this kind. I could not walk very well and I felt nauseous. I have enough experience having been around sports my entire life that this was not good.
I have a close friend that is a Dr and he was able to get me in to see the oldest and most prestigious Orthopedic Surgeons in the Kansas City area on that Monday.
The OS listened to my explanation, did the Thompson Test and schedule me for surgery July 1st. He seemed highly competent and confident and it was the most esteemed group. He spent all of 8 minutes with me.
He told me for the next two weeks I could work and put weight on it as I could stand it. So I spent the next two weeks working to get as much done as possible and had the surgery on July 1st. I wish I had spent some time doing a little research. I went in to this almost entirely unprepared. What should have been a warning sign for me in my abbreviated visit with my OS I actually took as a positive. He was the Sports Medicine surgeon, presented himself as completely positive, competent and self assured.
On July 1st I had my surgery late in the day. I will say from this experience have your surgery early. Late in the afternoon in an outpatient environment means that when you come around you are pushed out the door.
I met the anesthetist and he recommended a lower epidural. He also gave me some kind of nerve blocker that lasted for several hours post surgery. He put me under. The surgery lasted 45 minutes and the surgeon met with my family and told them all went well. It wasn’t frayed and he was able to put it together easily.
When I came around it was about 6PM and the place was cleared out. The nurse got me up, handed me some crutches and pretty much demanded I demonstrate my ability to use them. I was dizzy and still under the influence but I somehow managed to perform and I was out the door in a wheel chair and on my way home.
They gave me the lowest possible dosage of hydrocodone. We did not keep up on the drugs. Once we got behind we never caught up. I was in pain through the weekend and finally on July 5th when I was freed to take Ibuprofen I had some relief. The swelling abated and I was able to finally sleep. It was a tough stretch. I wish they had given me the strongest dosage of hydrocodone. Or something stronger.
I was casted and on my back with my foot elevated and then I began to research what I had gotten myself into. I came across this blog. In many ways it was too late. I had no idea that there was a non surgical option which NormoftheNorth has tried to help educate on. I did not know that there was widespread disagreement about treatment protocol either or that I should have interviewed my surgeon. Etc… I am mildly surprised at this in me as I normally don’t trust Doctors all that much.
After research on this site I purchased the I walk free crutch. It is helpful but hard to take on and off. Also, you have to cinch it down pretty tight and going down stairs can be harrowing, but thrilling if you like living on the edge. I will use it when I plan on being on my feet for extended times. You are hands free after all.
The truly exciting product I discovered was the VACOped Cast and the protocol that goes along with it. I was excited as there seemed to be some ray of light in this dark process. I asked my OS to prescribe it for me and he did. I have the cast in my possession and it is a stellar product. Also, Matt Carroll is extremely oriented to helping and instructing. BUY this boot is all I can say.
On my second week to visit my OS I came with the boot, and the results of my research work on the internet to support the change in protocol that I realized I was potentially introducing. I had highlighted the salient points in each study.
To my dismay my OS would not look at, touch or even consider changing his ultra conservative approach. He does not want to engage the patient in any kind of dialogue. He doesn’t even want to explain what comes next. He simply want you to get casted and come back in two weeks to find out what happens next.
I asked him to consider the boot and his response was that I would take it off and that was the sole and single reason I ordered it. I told him I wouldn’t take the boot off and he then said that his ex wife had lied to him and he didn’t need anyone else lying to him as well. I was shocked and didn’t quite know how to respond. What I had hoped would be an objective conversation now took on moral overtones to such a degree that if I left with the cast I essentially was admitting that I was a liar. This was highly unprofessional. He ended this brief monologue by declaring that after all it was my Achilles. That he was certain I would re-rupture and when I did he could not fix it and I would be permanently impaired.
I knew that if I chose the boot my care was now in my hands and he was essentially absolving himself of any further responsibility. I lacked the confidence and certainty to take this step.
So here I sit with a cast on my leg and the stellar state of the art boot sitting across the living room. I am uncertain as to how to proceed. He told me that I would be at least 6 more weeks non weight bearing. According to what I have read that is way overdoing the non weight bearing. In fact the atrophy will be terrible, the tendon stiff, the rehab elongated and the risk of adhesions increased. Perhaps I am wrong but that seems to be the conclusions to which I have arrived.
In summary I invite any input on these questions. I think and hope that any information will be helpful to others.
1. Should I try to find another OS to take me on that will embrace the boot and its protocol? I have heard that it is hard to get another OS to take you after you have had surgery from someone else.
2. Should I simply demand that I be put into the boot and write my own rehab protocol. I am very uncertain here as I feel that he has sort of threatened me.
3. If I do does anyone have a specific protocol that I can print off and follow?
4. Does anyone know of any Os in the Kansas/Missouri region that utilizes the VACO ped Pro or boot? Matt Carroll of VACOped has told me that he does not know of a single boot he has sold in the Kansas City area. I am going to call him and see if he has sold any in Columbia or St Louis.
5. Should I just continue the ultra conservative protocol that my OS has outlined? My brother in law is an Emergency Room Dr and one of my closest friends is a BHRT Dr. and both of them have indicated that I should consider this in the grand scheme as a bump in the road and just stick with him.
I know I have been long winded here. This is my first blog and I will curtail them in the future. Thanks to whomever for reading and providing any input you might consider helpful.

5 Responses to “Journey Begins with ???”

I was in a similar position concerning rehab and simply followed my own protocol after getting into a boot at 3 weeks. I was happy with the surgery but not the rehab. Luckily I did not have to deal with your cast situation.

Here is a protocol from the US Army:
wbamc.amedd.army.mil/Documents/PatientCare/PostOpRehabProtocols/Achilles Repair WB08.pdf

Another from a university PT program:
/xnet.kp.org/socal_rehabspecialists/ptr_library/09FootRegion/26Ankle-AchillesTendonRepair.pdf

If you go doc’s way and re-rupture you get more of the same style treatment assuming you keep the doc.

If you go your own way and re-rupture doc may refuse to see you again but you’d probably want a different doc anyway.

JSKI
Thanks for the helpful insight. It appears that I am going to have to structure my own rehab program. I may wait out this new two week period and when i next see my OS demand that the cast be removed and I make my own transition to the boot and get set up with a PT specialist. They may not even agree to treat outside of the surgeons approval.

Tony, I’m in no position to complain about long-winded blogs and posts, as you already know! And I appreciated the details, too.

I think you already know where to find the “UWO” protocol that a few of us here (and 145 patients in the UWO study) have followed, at bit.ly/UWOProtocol .

Your OS sounds pretty awful, or at least like a human being going through a tough patch and taking it out on the people around him. His approach and his protocol both seem archaic.

Many surgeons, including yours (and mine 8 yrs ago) follow instincts that are basically backwards — they think that longer immobilization is safer, more “conservative”, and more likely to produce superior results, while the evidence generally points exactly the other way. In addition, they place no value on the lifestyle and psychological benefits of early weight-bearing and mobility, except to view them as a threat or a challenge to be overcome. And they give little weight to the non-trivial risks of injury from being on crutches for weeks and weeks.

The only good thing I can say about that kind of ultra-conservative protocol is that I survived it myself (post-op, first ATR, 8 years ago), and the final results were just fine. Getting there was a real PITA, and I was constantly arguing with my OS — I eventually became his first patient EVER to be put into a (hinged) walking boot, instead of one or two MORE casts (I had THREE before the boot!). But I did get there, and I was playing competitive volleyball again, with no noticeable functional deficit, at around 10 months post-op.

Buy the evidence (and some other anecdotes you can read here) shows that it’s not the best way to go, for sure.

Tony, things are slightly different here in the UK. In fact treatment varies from one primary care trust to another and between hospitals in the same trust.

While patients are treated under a particular consultant, it happens that you may see 5 different consultants but not the one you’re registered under! Each belonging to a different school of thought with regards to treatment options (op, non-op, boot, cast…)

Your consultant is an asshole; he obviously doesn’t like being told what to do, esp from patients! Any chance you can see another consultant at the same hospital, try booking a different day slot.

As norm suggested, the old school conform to immobilsation for min 6 weeks - which simply isnt evidence based.

I’m careful not to encourage you to wear the boot, in the event he removes you from his care, which happens in the UK. You will forfeit any physio

Issat,
Thanks for taking the time to give helpful insight. Tomorrow I am going to see if there is another OS in the practice who is more progressive without mentioning i already had surgery.
Also, I am going to call a couple in the KC area that I have come across that utilize boots.
I think worst case for me is at the four week post surgery I simply refuse another cast.

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Actually that business about people believing the earth was flat around the time Columbus got lost crossing the Atlantic is completely false and was fabricated by Washington Irving in his biography of Columbus. People had know the earth was round for at least several centuries by then. The ancient Egyptians and Greeks, among others, weren’t “flat earthers.”

Despite all the sensible-sounding advice to “take it easy”, “make sure”, “better safe than sorry”, suggesting that slower rehabs decrease re-rupture rates, the actual **evidence** generally shows the exact opposite! I don’t think the VacoCast protocol has ever been tested in a good-sized study, and I’m not sure about Dr. Berkson’s or the one from Berlin. (Please correct me if I’m wrong.)
But the similar fast one at bit.ly/UWOProtocol HAS been subjected to a good-sized study, published in 2010,and it produced excellent results with and without surgery! That study (with results) is linked in “ATR Rehab Protocols, Publications, Studies” on the Main Page.
For a LONG time, humans thought the Earth was flat, because it seemed logical. Then it was obviously logical that the plates of the Earth did NOT move around. . . Thinking that slow rehab is “conservative” and “safe” belongs in that same discard pile!
That doesn’t mean anybody should go nuts or be careless, but following a good fast modern protocol that produced excellent results is apparently very good for the leg — and it’s great for the lifestyle and the psyche!

As I look forward to spending three months on one leg and crutches after pelvic bone graft it is interesting to come across someone else’s non weight-bearing experiences. It does take an awful lot of patience. And when it’s all over I have to start all over again with a hip revision on the other leg.

I do hope you are fully recovered now. Your own problem sounds very much like my daughter had recently after an accident.

Vernon said: “The boot was the best decision I made, with out it I would be crazy and probably weeks or months behind in my recovery,”
I agree, a good friend of mine had the same injury and to quote him: This boot is the best f… thing out there.

I know it’s a bit late after you all asked the question but I thought I would respond for the benefit of those who will be reading this blog in the future. A little background, I’m 43, male fit & no history of ankle injury, did this playing sport and limped around at work for 2 days before I got a doctors certificate to say no work, had surgery.

I went out and bought the Vaco boot as well, mine has the notches on the back that go from 3 to -1 which I assume are from 30 degree’s to -10 degree’s. ( It relates back to the paperwork that came with the boot).

My surgeon was reluctant to put me in a boot initially, until I showed him a picture of the Vaco boot and the way it could be locked in at any set angle, he said as long as your foot can be locked at 30 degree’s (toes pointing to the ground in other words) I could use it.

So at 2 weeks post surgery I set the boot to 30 degrees and put it on. The surgeon said I’ll see you in 6 weeks and walked out. So I figured I’ll follow the recommended recovery process put out by Oped Vaco and Charite’ Hospital in Berlin.
At 3 weeks I was weight bearing and 25 deg, 4 weeks ful

Norm, Odd as it is, I did not even know I had the problem. I am on the FEMA Urban Search and Rescue team which requires an annual physical. When it was all over the dac asked if there was anything else that may be bothering me. I told him my tendon bothered me some when I walk. That led to an xray, which led to an MRI, which led to surgery. I think I was in mild shock through the ordeal.

Tom, I don’t think I’ve heard of another case of an ATR that was so gradual the patient wasn’t sure when it happened. Many people don’t realize it’s an ATR for some time, of course, but they usually know exactly when whatever-it-was happened. Anyway, good to hear you seem to be coming through the ordeal!

Norm, Thanks for the comments. I try to figure out when I could have originaly tore my AT. All I had was the onset of pain. It was mild at first then it continually got worse. I hunt, and golf (a lot). I dont see how either of those activities did anything however I have been at a loss for how it happened. I was allowed FWB at 7 week after the first surgery and re-tore it all after the first step. Then my doc deployed to Iraq. (I am retired military). I was farmed oput to a civilian doctor and whew, am I happy with him. He did a complete rebuild including cadaver parts and rerouting a foot tendon which was also tore. The entire ordeal was a nightmare but I am now FWB in the boot and in a running shoe around the house. I am seeing the light at the end of the tunnel.

Tom, there are a few of us here who tore our ATs playing aggressive and competitive sports, even though we don’t even REMEMBER being 57 years old! Of course, memory is the first thing to go. . . and then there’s also loss of memory!

Wow. I just joined this site and although I don’t know what the heck I am doing yet, I fell into your blog on being a second timer. I am as well. 1st surgery November 30, reinjured in January, Complete rebuild on May 5th. It has been a long road, and as “sick” as it sounds, it’s good to see I am not alone in this. I am almost 12 weeks post surgery, still in the boot and in PT. I seem to be making tremendous progress since pain and swelling lasted 8 weeks. On my retear I took two other tendons down as well so slow going is the name of my game. I was already informed another tear and it is bone-fusion for me. I am 57 years old (tomorrow) and although I am in good shape, things dont heal so quick at my age. I will be monitoring your progress and hope to learn and share as soon as I figure this place out. Thanks for your posting and “one foot at a time” with thought before each step.

Tony, out of the frying pan into the fire so to speak. I’m a second timer, re-tore when I did too much to fast, mainly due to lack of direction and info, like your OS, mine too was busy and brief on visits. I too had to get the vacocast on my own. My doc wasn’t into the hinged boot but allowed me to work with it. Right now I would start out in as much plantar flex as you need to feel comfortable. Don’t get locked into time, go by how it feels. If it doesn’t feel right it probably isn’t My post surgical time, I went into a fixed boot 2 wks out from surgery. When they took me out of the cast and said to put the boot on I thought I was going to passout from the pain. I had asked the doc how much does it hurt, “its uncomfortable” nurse said the same. Well I was wheeled out to my car in a wheel chair. It took about 12 hrs to calm down and I could walk on it. I would imagine you will be similar. Ice a elevate today. Start with both feet on the ground sitting and see how it goes, don’t try to go past neutral anytime soon. While sitting you can unlock the plantar flex and do gentle ROM, pushing foot down it will help loosen

Second, most of the modern protocols introduce WB before they stretch you to neutral. E.g., “my” UWO Protocol gets to FWB about 2 weeks before the heel wedges come out. I like that approach better than your Doc’s.

Resting your foot on the floor is not even PWB, in my books. When you sit, you’ve been resting your foot on the floor all along (unless you’re elevating), haven’t you? PWB can start at close to 0% of FWB, but it usually gets to 25% and even 50% fairly soon. The UWO Protocol starts that progression at TWO weeks, so I don’t think it’s premature for you. But combining it with the ankle stretch (moving toward neutral) may be too much at once.

If/when you change angle toward neutral, maybe especially after you’re PWB, it seems best to do it before bed. Your leg has an easy time in bed, and the sleep time gives your ankle a chance to get used to the extra stretch, before you add any weight or even drop it down and make it more inflamed.

Sounds like you switched from an angry Doc to one who’s unengaged, maybe bored. That’s lots not to be impressed by! I guess bein

Norm as always your replies are excellent and informative.
I mistyped lef for leg. i have been in the position where my bad side (left) leg is always bent. Either in an elevated positionn slightly bent or on crutches slightly bent. When i straighten out my left leg i feel a burning, pulling sensation that runs from my smallest toe across the top outside of my foot and around to the back of my heel. I will say once i keep it straight for a short time the pain subsides. it is not acute but it does hurt a bit.

I have grown a little concerned about the actual surgery. After the expereince I had with my OS I began to lose confidence that he actually did decent work.

I am probably overly paranoid and this is just normal healinng. As I am sure we are all focused on how this part of our body feels.

thanks for the rest of the informationn on PWB and FWB as tolerated. What a lot to look forward to I have!

It is helpful to know all of us are in the same process. Misery does love company and a sad face cheers the heart. This really demonstrates what relatonal communal beings we are doesnt it?

I don’t think I’ve found a VacoPed/VacoCast user who ISN’T an advertisement for the boot, and the company! I’ve never used it myself, but it sounds very good to me from the reports. (Not good enough for me to try to grow a third AT, but very good!) And I’ve been sold on HINGED BOOTS all along, since I first used one.

Using it for a year is silly, but it’s a useful tool for protecting yourself in high-risk situations and still getting good calf exercise, long after you’re padding around your home in shoes or barefoot.

You say you “feel uneasy as this pain is not something that you just work through. I dont trust myself in this arena and am very concerned to rerupture.” EXACTLY!! Keep that attitude, and you’ll probably apply the right kinds of judgments. “Cautious, sensible impatience” sounds about right to me.

Nobody really knows what PWB means. Some pros have their patients push down on a scale to calibrate the pressure in pounds — but the target pressure (in pounds) is a number they kind of picked out of a hat, so it’s kind of misleadingly precise.

Issat,
Thanks for taking the time to give helpful insight. Tomorrow I am going to see if there is another OS in the practice who is more progressive without mentioning i already had surgery.
Also, I am going to call a couple in the KC area that I have come across that utilize boots.
I think worst case for me is at the four week post surgery I simply refuse another cast.

Tony, things are slightly different here in the UK. In fact treatment varies from one primary care trust to another and between hospitals in the same trust.

While patients are treated under a particular consultant, it happens that you may see 5 different consultants but not the one you’re registered under! Each belonging to a different school of thought with regards to treatment options (op, non-op, boot, cast…)

Your consultant is an asshole; he obviously doesn’t like being told what to do, esp from patients! Any chance you can see another consultant at the same hospital, try booking a different day slot.

As norm suggested, the old school conform to immobilsation for min 6 weeks - which simply isnt evidence based.

I’m careful not to encourage you to wear the boot, in the event he removes you from his care, which happens in the UK. You will forfeit any physio

Tony, I’m in no position to complain about long-winded blogs and posts, as you already know! And I appreciated the details, too.

I think you already know where to find the “UWO” protocol that a few of us here (and 145 patients in the UWO study) have followed, at bit.ly/UWOProtocol .

Your OS sounds pretty awful, or at least like a human being going through a tough patch and taking it out on the people around him. His approach and his protocol both seem archaic.

Many surgeons, including yours (and mine 8 yrs ago) follow instincts that are basically backwards — they think that longer immobilization is safer, more “conservative”, and more likely to produce superior results, while the evidence generally points exactly the other way. In addition, they place no value on the lifestyle and psychological benefits of early weight-bearing and mobility, except to view them as a threat or a challenge to be overcome. And they give little weight to the non-trivial risks of injury from being on crutches for weeks and weeks.

The only good thing I can say about that kind of ultra-conservative protocol is that I survived it myself (post-o

JSKI
Thanks for the helpful insight. It appears that I am going to have to structure my own rehab program. I may wait out this new two week period and when i next see my OS demand that the cast be removed and I make my own transition to the boot and get set up with a PT specialist. They may not even agree to treat outside of the surgeons approval.

I was in a similar position concerning rehab and simply followed my own protocol after getting into a boot at 3 weeks. I was happy with the surgery but not the rehab. Luckily I did not have to deal with your cast situation.

Here is a protocol from the US Army:
wbamc.amedd.army.mil/Documents/PatientCare/PostOpRehabProtocols/Achilles Repair WB08.pdf

Another from a university PT program:
/xnet.kp.org/socal_rehabspecialists/ptr_library/09FootRegion/26Ankle-AchillesTendonRepair.pdf

If you go doc’s way and re-rupture you get more of the same style treatment assuming you keep the doc.

If you go your own way and re-rupture doc may refuse to see you again but you’d probably want a different doc anyway.